The Health Protection Agency (HPA) issued its annual
epidemiological report yesterday, and drew particular attention to the need
for improvement in HIV testing rates – six of its eight recommendations concern
The headline findings concerning new HIV diagnoses were
reported on Aidsmap six weeks ago, but to recap:
- In 2011, there were 3010 new diagnoses among
gay men, the highest annual figure ever.
- There were 2990 new diagnoses among
heterosexual men and women.
- While the number of heterosexual infections has decreased in recent years, the proportion of infections acquired in the UK has increased.
- An estimated 96,000 people were living with HIV,
but 24% of them were unaware of their infection.
- HIV prevalence in the general population was
0.15%, but was considerably higher in the black African community (3.7%) and
among men who have sex with men (4.7%).
Among those who are newly diagnosed, 47% were diagnosed
late (with a CD4 cell count below 350 cells/mm3). While this statistic
is an improvement on 2002’s figure of 60%, the UK still performs
poorly in comparison to some other countries.
Inequalities are apparent too – while 35% of gay and
bisexual men were diagnosed late, 56% of heterosexual women and 64% of
heterosexual men were diagnosed late. Amongst the heterosexual people, late diagnosis
rates were highest in those of black African ethnicity.
Whereas people who attend sexual health clinics usually have
an HIV test during their visit (70% of all attendees, 84% of gay and bisexual
men) and coverage is extremely high at antenatal clinics (97%), the same cannot
be said for other settings.
An HPA audit done with 40 sexual health commissioners in
high-prevalence areas found that only 31% had commissioned HIV testing for some
new patient registrations at GP surgeries, and just 14% had commissioned
routine HIV testing as part of general medical admissions to hospitals.
Guidelines from both the BHIVA and NICE recommend testing in these settings.
The HPA include the following in their recommendations:
- In areas of high prevalence, implementation of
routine HIV testing for all general medical admissions and new GP patients.
- Clinicians should take every opportunity to
offer and recommend HIV testing to men who have sex with men and people of
black African or Caribbean ethnicity.
- Every effort should be made to reduce
health service barriers to HIV testing.
Commenting on the report, Deborah Jack of the National AIDS
Trust (NAT) made a connection between the higher rates of late diagnosis in
black African people and the poor provision of HIV testing in GP surgeries. “We
know that African people are three times more likely to be diagnosed through
their GP than a sexual health clinic,” she said, urging more commissioning of
HIV testing in general practice. “We are seeing huge inequalities in accessing
In terms of inequalities, the HPA’s report also draws
attention to the uneven geographical spread of HIV around the country, with
particular concentrations in areas with more socioeconomic problems.
In 2011, there were 58 local authorities in which more than 2 in 1000
residents had diagnosed HIV, and 30 of these local authorities were in London.
There were 22 local authorities with a prevalence above 4 in 1000, and 18 of
these were also in London. (The non-metropolitan areas were Brighton & Hove,
Manchester, Salford and Luton).
Within London, in the most deprived boroughs (defined with
reference to a range of economic, social and housing indicators), 8 in 1000
people had diagnosed HIV. In the least deprived boroughs, 1.5 in 1000 had
HIV. The same pattern could be seen in England as a whole, although the figures were not as stark.
The HPA have also begun to publish data for each local
authority on rates of late diagnosis, in order to put the spotlight on areas
which perform relatively poorly. They recommend that local authorities and NHS
bodies prioritise HIV testing in Joint Strategic Needs Assessments in order to
Returning to HIV testing within sexual health clinics, the
report includes a new analysis, showing that almost two-thirds (63%) of gay and
bisexual men who were newly diagnosed with HIV at a sexual health clinic had
not attended that clinic for testing in the previous three years. This, the HPA
says, strongly suggests that there is room for improvement in the frequency of
testing by those at highest risk.
To that end, they recommend that men who have sex with men
should test for HIV and sexually transmitted infections at least annually, and
every three months if having unprotected sex with new or casual partners. Black
African and Caribbean people who have unprotected sex with new or casual
partners are advised to test regularly, although the frequency is not defined.
The HPA also report high rates of sexually transmitted
infection amongst gay men who are newly diagnosed with HIV – 21% of new HIV
diagnoses were accompanied by an STI (compared to 3-4% in heterosexual people).
And the National AIDS Trust point to HPA data
which suggest that having a sexually transmitted infection can be a predictor
of future HIV acquisition. Gay men
diagnosed with chlamydia were three times more likely to
acquire HIV in the following year and gay men diagnosed with
gonorrhoea were nearly two and half times more likely to
get HIV in the following year.
This is essentially because STIs are indicators of risk
behaviour which may lead to HIV transmission in the future. In addition, those
who have both HIV and an STI are much more likely to pass on HIV than they
otherwise would be.
“A key lesson from the HPA report is that if you don't take
STIs seriously you're not taking HIV seriously,” Deborah Jack of NAT said. “Most STIs
may be treatable and curable but they are not just some 'occupational hazard'
of gay life – they are inextricably connected to the spread of HIV.”
“HIV negative gay men diagnosed with an STI should really
treat it as a 'wake up call',” she continued. “You are at serious risk of
getting HIV in the near future and need to take steps to prevent that happening.”